Image-guided spine surgery: state of the art and future directions

Navigation technology is a widely available tool in spine surgery and has become a part of clinical routine in many centers. The issue of where and when navigation technology should be used is still an issue of debate. It is the aim of this study to give an overview on the current knowledge concerning the technical capabilities of image-guided approaches and to discuss possible future directions of research and implementation of this technique. Based on a Medline search total of 1,462 publications published until October 2008 were retrieved. The abstracts were scanned manually for relevance to the topics of navigated spine surgery in the cervical spine, the thoracic spine, the lumbar spine, as well as ventral spine surgery, radiation exposure, tumor surgery and cost-effectivity in navigated spine surgery. Papers not contributing to these subjects were deleted resulting in 276 papers that were included in the analysis. Image-guided approaches have been investigated and partially implemented into clinical routine in virtually any field of spine surgery. However, the data available is mostly limited to small clinical series, case reports or retrospective studies. Only two RCTs and one metaanalysis have been retrieved. Concerning the most popular application of image-guided approaches, pedicle screw insertion, the evidence of clinical benefit in the most critical areas, e.g. the thoracic spine, is still lacking. In many other areas of spine surgery, e.g. ventral spine surgery or tumor surgery, image-guided approaches are still in an experimental stage. The technical development of image-guided techniques has reached a high level as the accuracies that can be achieved technically meet the anatomical demands. However, there is evidence that the interaction between the surgeon (‘human factor’) and the navigation system is a source of inaccuracy. It is concluded that more effort needs to be spend to understand this interaction.     

Venous thromboembolism in spine surgery: Review of the current literature and future directions

Venous thromboembolism (VTE) is a serious adverse event that can profoundly affect the neurologic recovery and rehabilitation of spine patients. While routine pharmacologic VTE prophylaxis has been implemented in other orthopaedic surgical subspecialties its use has not been recommended in spinal surgery. Concern regarding post-operative spinal epidural hematoma and its devastating sequelae are a major focus of the discussion surrounding routine VTE prophylaxis in spine surgery. While pharmacologic prophylaxis may be beneficial in high risk patients, further large scale, prospective analyses are necessary to elucidate the role and risks of routine VTE screening and pharmacologic prophylaxis in spine surgery patients.     

Radiation exposure to the patient and operating room personnel during percutaneous nephrolithotomy

Introduction: The increased use of fluoroscopy during percutaneous nephrolithotomy (PCNL) places the urologist and operating room personnel at an occupational risk for measurable radiation exposure. We evaluated the degree of radiation exposure received by the patient and operating room personnel at our endourology facility during PCNL. Patients and method: The incident radiation dose to the patient and the urologist during 50 consecutive PCNL procedures was monitored using lithium fluoride thermo-luminescent dosimeter chips (TLD chips). A hand held radiation survey meter was used to measure the radiation in air at different positions occupied by various operating room personnel. The approximate distances of the various personnel from the X-ray tube were also measured. Results: PCNL was performed upon 35 males and 15 females. The average time for the procedure was 75 minutes (range: 30–150 min). The mean fluoroscopy screening time during the procedure was 6.04 min (range 1.8–12.16 min) with a mean fluoroscopy tube potential of 68 kVp and a mean tube current of 2.76 mA. The mean radiation exposure dose to the patient was 0.56 mSv (SD ± 0.35), while the mean incident radiation exposure to the finger of the urologist was 0.28 mSv (SD ± 0.13). Conclusion: The various operating room personnel are within safe radiation dose limits during PCNL. Efficient fluoroscopy further reduces the radiation scatter. All occupational personnel should ‘achieve as low as reasonably achievable’ dose by adhering to good practices.     

脊柱微创手术的辐射危害及其防护进展

医学影像学是现代医学最重要的诊断工具之一,术中X线透视检查因可实时获得患者的骨骼结构信息和可移动便利性而被广泛使用于脊柱手术中[1]。脊柱微创手术近年来因其创伤小、出血少、创口美观、感染几率小、术后恢复快、疗效相当而得到迅速的发展并在全世界各地得到广泛推广[2～4],现已明确可应用于脊柱退行性疾病[5]、脊柱畸形[6]、外伤[7]和肿瘤[8]等。然而,由于脊柱微创手术经常需要在X射线透视下进行定位和复位检查,所以脊柱外科医生的辐射危害是临床上不容忽视的问题[9]。高剂量辐射可以诱发肿瘤、白内障、心血管疾病等,低剂量辐射暴露与肿瘤、白内障、心血管疾病等联系也是当下研究的热点[10～13]。增强对辐射危害的基本认识,提高辐射的防范意识,掌握减少辐射暴露的原则与方法是每一位脊柱外科医生的职业健康的必修课[3、14]。笔者就脊柱微创手术的辐射危害及其防护进展综述如下。     

脊柱微创手术中患者辐射暴露和应对措施的研究进展

正在脊柱外科手术中,由于术中放射仪器的使用,几乎所有人体组织均可观察到辐射暴露的组织效应~([1]),术中高剂量放射可引起皮肤红斑、白内障形成、甲状腺肿瘤和其他恶性肿瘤等一系列并发症的产生~([2、3])。患者遭受的辐射暴露主要与以下方面相关:(1)总透视时间,包括定位及术中操作所需透视时间~([4]);(2)透视位置,侧位透视产生的直接辐射和散射辐射分别是正位透视的200倍和30倍~([5]);(3)患者体重及体积,有研究表明,严重肥胖(BMI35)与辐射暴露显著相关~([6])。且射线输出和皮肤与辐射源的距离取决于患者体积大小,对于体积较大患者,射线输出增加以保     

Nitrous oxide exposure in the operating room

One-hundred and eight-five pairs of gas samples were collected from inspired gas (10 cm behind the head at nose level) and end-tidal gas of persons administering anesthesia in 3 operating rooms during daily routine anesthesia. Mean operating-room N2O concentrations from 22 to 144 ppm (volume/volume [V/V]) were measured by gas chromatography, and large moment-to-moment variations (temporal gradients) were seen in individual operating rooms. Mean end-tidal N2O concentrations from 51 to 114 ppm (V/V) were observed. There were low correlations between inspired and end-tidal N2O concentrations (r values as low as r = 0.35). This poor relationship is presumably due to spatial and temporal gradients of N2O in the operating rooms. We conclude that the temporal and spatial gradients in N2O concentrations within active operating rooms are sufficiently large to invalidate estimation of exposure of anesthetic personnel to N2O from "spot" or "grab" samples collected in the breathing area.     

Blood exposure in the operating room: reducing the risk

Blood must be considered a toxic substance in the operating room. Members of the operating room team must exercise greater caution to prevent blood contact. Increased attention to the adequacy of barriers and avoidance of certain operating room behavior is important. All surgical team members must be vaccinated against hepatitis B. The frequency of operating room transmission of HIV infection is clearly less than has been the case with hepatitis B. Because of documented cases of occupationally acquired HIV following hollow needle exposures, it is clear that the risk is not zero. While no case of operating room transmission of HIV has yet been documented, it has no doubt occurred and will certainly be documented in the future. It is the responsibility of each member of the surgical team to be an advocate for his or her own protection in the operating room. A heightened awareness of our general behavior and particular attention to our use of sharp instruments and needles in the operating room will be our best line of defense.     

The operating room of the future: observations and commentary

The Operating Room of the Future is a construct upon which to develop the next generation of operating environments for the patient, surgeon, and operating team. Analysis of the suite of visions for the Operating Room of the Future reveals a broad set of goals, with a clear overall solution to create a safe environment for high-quality healthcare. The vision, although planned for the future, is based upon iteratively improving and integrating current systems, both technology and process. This must become the Operating Room of Today, which will require the enormous efforts described. An alternative future of the operating room, based upon emergence of disruptive technologies, is also presented.     

Making the operating room of the future safer

There is an increasing demand for interventions to improve patient safety, but there is limited data to guide such reform. In particular, because much of the existing research is outcome-driven, we have a limited understanding of the factors and process variations that influence safety in the operating room. In this article, we start with an overview of safety terminology, suggesting a model that emphasizes "safety" rather than "error" and that can encompass the spectrum of events occurring in the operating room. Next, we provide an introduction to techniques that can be used to understand safety at the point of care and we review the data that exists relating such studies to improved outcomes. Future work in this area will need to prospectively study the processes and factors that impact patient safety and vulnerability in the operating room.     

Telemedicine for the operating room of the future

Telemedicine is becoming a subset of information science and should benefit tremendously from the geometric growth of information architecture in hospitals. The use of telemedicine to break the isolation of the operating room is a highly achievable goal. An open operating room has information on demand for the personnel, fluid communication among operating room personnel, and broad interaction with the learner community and consultants. In an operating room with significant data capture, the patient is brought into the process not only as a real person, but also as a huge data set that acquires all the events of the surgery. The data include the visual, electrical, and mechanical events that define the surgical procedure. As part of a dynamic electronic medical record, they are available to those who are present and those who are asked to help from even a great distance away with real-time advice. The data are also available to those who seek to understand what happened to the patient afterwards for the purpose of root cause analysis, near miss analysis, instruction, or more accurate medical records.     

From the operating room of the present to the operating room of the future. Human-factors lessons learned from the minimally invasive surgery revolution

The minimally invasive surgical revolution has changed the way surgery is practiced. It has also helped surgical innovators to break the tethers that anchored the practice of surgery in an early 20th century operating room environment. To some in surgery, the Operating Room of the Future will be seen as a revolution but to others, an inevitable evolution of the changes ushered in by the adoption of minimally invasive surgery. Although minimally invasive surgery has conferred considerable advantages on the patient, it has imposed significant difficulties on the surgeon, which in turn, have impacted outcomes. These difficulties were primarily human factor in nature and were poorly understood by critical groups such as device manufacturers, surgeons, and surgery educators and trainers. This article details what these human factors were, how they related to the practice of minimally invasive surgery, and how they will impact on the practice of surgery in the Operating Room of the Future. Much of the technology for the Operating Room of the Future currently exists (eg, surgical robotics, virtual reality, and telemedicine). However, for it to function optimally it must be integrated in a fashion that takes on board the human factor strengths and limitations of the surgeon. These advanced technologies should then be harnessed to optimize surgical practice. In some cases, this will involve rethinking existing technologies (ie, three-dimensional camera systems), applying technologies that currently exist in a manner that is more systematic and better managed (ie, surgical robots and virtual reality), and a reconsideration of who should be applying these technologies for the practice of surgery in the 21st century. In all cases, there will be education and training implications for the practitioner. Lastly, there must be unequivocal demonstration that these changes bring about positive benefits for patients in terms of better outcomes and for surgeons in terms of ability and ease of doing their job. After the experiences of the last decade with minimally invasive surgery, the Operating Room of the Future should be seen as a well-grounded evolution, not a revolution.     

天玑骨科机器人辅助脊柱手术护理标准操作程序的建立与应用

目的 建立天玑骨科机器人辅助脊柱手术护理标准操作程序,并探讨其在临床中的应用效果。方法选择2019年7月至2020年6月行机器人辅助脊柱手术患者112例作为对照组,实行常规围术期护理措施。2020年7月至2021年6月的132例患者作为观察组,按照标准操作程序进行围术期护理。比较两组患者手术体位安置用时,机器人使用时间,围术期意外事件发生率及医生满意度。结果对照组术前体位安置所需时间、机器人使用时间及机器人运行意外事件发生率显著短于或低于对照组,医生满意度显著高于对照组（均P＜0.05）。结论天玑骨科机器人辅助脊柱手术护理标准操作程序的建立有效规范了手术室护士的护理行为,可提升手术室工作效率与护理质量。     

Minimally invasive surgery and technology: future directions

Springer-Verlag Berlin Heidelberg 00345 World Journal of Urology World J Urol 0724-4983 WJURDJ 018 004 10.1007/s003450000180235.345 http://link.springer. de/link/service/journals/00345/bibs/0018004/00180235.htm 00180235. 345 EDITORIAL 0235 0236 Springer-Verlag Berlin Heidelberg 2000 Minimally invasive surgery and technology: future directions Jeffrey A.Cadeddu Department of Urology, The University of Texas, Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9110, USA     

Three-dimensional electromechanical mapping: imaging in the operating room of the future

BACKGROUND: Three-dimensional electromechanical mapping has previously been shown to be a clinically important tool for cardiac imaging and intervention. We hypothesized that this technology may be beneficial as an intraoperative modality for assessing cardiac hemodynamics and viability during cardiac surgery. We report here the use of this technology as an imaging modality for intraoperative cardiac surgery. METHODS: The tip of a locatable catheter connected to an endocardial mapping and navigating system is accurately localized while simultaneously recording local electrical and mechanical functions. Thus the three-dimensional geometry of the beating cardiac chamber is reconstructed in real time. The system was tested on 6 goats that underwent acute dynamic cardiomyoplasty and on 5 dogs that underwent left anterior descending (LAD) coronary artery ligation. RESULTS: The electromechanical mapping system provided an accurate three-dimensional reconstruction of the beating left ventricle during cardiomyoplasty. After the wrapping procedure, significant end-diastolic area reduction was noted in the base and mid parts of the heart (948 +/- 194 mm2 vs 1245 +/- 33 mm2, p = 0.021; and 779 +/- 200 mm2 vs 1011 +/- 80 mm2, p = 0.016). The area of the cross-section of the apex did not change during the operation. Acute infarcted tissue was characterized 3 days after LAD ligation by concomitant deterioration in both electrical and mechanical function. CONCLUSIONS: By providing both a clear view of the anatomical changes that occur during cardiac surgery, and an accurate assessment of tissue viability, electroanatomic mapping may serve as an important adjunct tool for imaging and analysis of the heart during cardiac surgery     

Occupational risks of blood exposure in the operating room

Bloodborne pathogens continue to be a source of occupational infection for healthcare workers, but particularly for surgeons. Over 1 per cent of the U.S. population has one or more chronic viral infections. Hepatitis B is the infection that has the longest known role as an occupational pathogen, but infection with this virus is largely preventable with the use of the effective hepatitis B vaccine. Hepatitis C affects the largest number of people in the United States, and there is no vaccine available for the prevention of this infection. HIV infection still has not been associated with a documented transmission in the operating room environment, but six cases of probable occupational transmission have been reported. A total of 57 healthcare workers have had documented occupational infection since the epidemic of HIV infection began. Infection of blood-borne pathogens to patients from infected surgeons remains a concern. Surgeons who are e-antigen-positive for hepatitis B have been well documented to be an infection risk to patients in the operating room. Only four surgeons have been documented to transmit hepatitis C, although other transmissions have occurred in the care of patients when practices of infection control have been violated. No surgical transmission of HIV to a patient has been identified at this time. Prevention of occupational infection requires use of protective barriers, avoidance of exposure risk by modification of techniques, and a constant awareness of sharp instruments in the operating room. Blood exposure in the operating room carries risk of infection and should be avoided. It is likely that other infectious agents will emerge as operating room threats. Surgeons must maintain vigilance in avoiding blood exposure and percutaneous injury.